Analyzing implementation of public health interventions : a need for rigor, and the challenges of stakeholder involvement

OBJECTIVES

This article shows how conceptual models can help to develop and evaluate public health interventions. It also reports on the challenges of getting stakeholders involved.

METHOD

The analysis is based on the reflexive approach applied by the authors during their participation in two public health intervention research (PHIR) projects, in France and in Burkina Faso.

RESULTS

In Paris, PHIR aimed to enable sub-Saharan immigrants to appropriate the existing means of prevention and sexual health care and to strengthen their empowerment in view of preserving their health. Evaluation was carried out using mixed methods. The intervention process theory is based on Ninacs' conceptual model of individual empowerment. The Consolidated Framework For Implementation Research (CFIR) was mobilized a posteriori to analyze the process. PHIR stemmed from collaboration between a research team and two associations. The different stakeholders were involved in the evaluation process, as were, at certain times, persons in highly precarious situations. In Ouagadougou, a community-based dengue vector control intervention was deployed to address an essential but neglected need. As regards evaluation, we opted for a holistic, mixed method approach (effectiveness and process). The contents of the intervention were determined based on tacit knowledge, a community preference survey and solid evidence. The theoretical framework of the intervention consisted in an eco-biological model of vector control. The implementation analysis combined an internal assessment of implementation fidelity with an external CFIR process analysis. All stakeholders were involved in the evaluation process.

DISCUSSION

Analysis confirmed not only the value of process evaluations in PHIR, but also the primordial importance of a rigorous approach. Stakeholder involvement is a major challenge to be addressed early in the planning of RISPs; with this in mind, effective and ethically sound assessment mechanisms need to be drawn up. Interdisciplinary evaluative approaches should be preferred, and the use of justified, relevant, and flexible frameworks is highly recommended.

CONCLUSION

Lessons learned for those wishing to engage in the process evaluation of a public health intervention are hereby presented.

Recentering neuroscience on behavior: The interface between brain and environment is a privileged level of control of neural activity

Despite the huge and constant progress in the molecular and cellular neuroscience fields, our capability to understand brain alterations and treat mental illness is still limited. Therefore, a paradigm shift able to overcome such limitation is warranted. Behavior and the associated mental states are the interface between the central nervous system and the living environment. Since, in any system, the interface is a key regulator of system organization, behavior is proposed here as a unique and privileged level of control and orchestration of brain structure and activity. This view has relevant scientific and clinical implications. First, the study of behavior represents a singular starting point for the investigation of neural activity in an integrated and comprehensive fashion. Second, behavioral changes, accomplished through psychotherapy or environmental interventions, are expected to have the highest impact to specifically reorganize the complexity of the human mind and thus achieve a solid and long-lasting improvement in mental health.

Evaluation of an ultrasound program in nationwide Continuing Professional Development (CPD) in Korean public health and medical institutions

BACKGROUND

The Education and Training Centre for Public Healthcare of the National Medical Centre plays a key role in providing continuing professional development (CPD) to 221 public health and medical institutions in South Korea. To assess the realization of the Centre's core value and the intended changes, program evaluations are required. The context, input, process, and product (CIPP) model is particularly suitable for evaluating CPD in the public sector, as it allows for recognizing the dynamic nature of the program environment.

METHODS

This research applied the CIPP model to the evaluation of CPD programs, particularly abdominal and thoracic ultrasound programs implemented in 2017 and 2018. Data were collected from 2017 to 2019. The program and its feedback were reviewed in the context evaluation. Based on this, a subsequent program strategy was established for the input evaluation. Observing the program in real time and recording its progress was followed in process evaluation. Finally, the outcomes and impacts of the program were reviewed and compared with baseline data in the product evaluation.

RESULTS

In context evaluation, the educational needs of the Centre's CPD program recipients, impediments that inhibit participation in education, and resources that the Centre can utilize were identified through an online survey, focus group interviews and expert consultation. Through input evaluation, we identified the best alternative that satisfied all pre-selected criteria, which were responsiveness to priority system needs, potential effectiveness, fit with existing services, affordability, and administrative feasibility. Observing the program in real time and recording its progress were conducted in process evaluation, demonstrating that the augmented program went as planned, and even had to be expanded due to increased demand. The impact of the program was measured, interpreted, and assessed in the product evaluation. The review committee decided that the intended change had been occurred, thus the Centre decided to maintain the program.

CONCLUSION

A thorough evaluation is necessary to determine the potential benefits of CPD. The CIPP methodology is valuable for executing formative and summative evaluations. The CIPP model is particularly useful for securing accountability data for large-scale nationwide educational programs supplied by public funds.

Response surface optimization and modeling in heavy metal removal from wastewater-a critical review

The existence of hazardous heavy metals in aquatic settings causes health risks to humans, prompting researchers to devise effective methods for removing these pollutants from drinking water and wastewater. To obtain optimum removal efficiencies and sorption capacities of the contaminants on the sorbent materials, it is normally necessary to optimize the purification technology to attain the optimum value of the independent process variables. This review discusses the most current advancements in using various adsorbents for heavy metal remediation, as well as the modeling and optimization of the adsorption process independent factors by response surface methodology. The remarkable efficiency of the response surface methodology for the extraction of the various heavy metal ions from aqueous systems by various types of adsorbents is confirmed in this critical review. For the first time, this review also identifies several gaps in the optimization of adsorption process factors that need to be addressed. The comprehensive analysis and conclusions in this review should also be useful to industry players, engineers, environmentalists, scientists, and other motivated researchers interested in the use of the various adsorbents and optimization methods or tools in environmental pollution cleanup.

[German-language translation of the PANELVIEW instrument to evaluate the guideline development process from the perspective of the guideline group]

INTRODUCTION

The development process for clinical guidelines is influenced by factors that are relevant to the validity of a guideline but often are not captured sufficiently in the final guideline documents. PANELVIEW is an English-language tool that can be used to explore the guideline development process from the perspective of guideline group members. Our aim was to translate the PANELVIEW tool into German, taking into account national contexts and linguistic differences.

METHODS

The PANELVIEW tool was initially translated by a core team, then refined and approved by a group of experts in a consensus-based Delphi process. The experts were selected on the basis of their experience in guideline development covering different fields (clinical, methodological, organisational, health professional, patient perspective) and geographical regions (Germany, Austria, Switzerland). A representative of the original PANELVIEW team was also involved. The Delphi steps included an online survey, an online consensus conference and final approval by circulating the results via email. Individual items were seen as generally agreed upon if the level of agreement in the respective steps was 75 % or more.

RESULTS

The expert group consisted of 12 persons. Of these, 11 (92 %) participated in the online survey and 10 (83 %) in the subsequent consensus conference. After the first Delphi step, sufficient agreement was achieved for 19 of 34 items (56 %). The remaining 15 items were discussed in the consensus conference and finally obtained 100 % agreement. The discussion focused on clarifying and adapting terms whose meaning was ambiguous or inadequate in the German context, which led to a deviation from the original wording in some instances.

DISCUSSION

The PANELVIEW tool was translated into German by means of a Delphi process. PANELVIEW complements existing instruments for assessing the methodological quality of guidelines by capturing the perspective of the guideline group. This will enable guideline developers and organisations to identify problems in the drafting process and avoid them in future projects. User testing and validation of the German-language PANELVIEW tool are planned for the future.

CONCLUSION

The German-language translation of PANELVIEW will enable guideline developers in German-speaking countries to continuously evaluate and, where necessary, improve the process and methods of guideline development.

Reducing infantile anemia: insight on patterns of process and outcome indicators by ethnicity and socioeconomic class during a 10-year intervention program and 5 years after

Background

In 2005, Clalit Health Services (CHS), the largest health maintenance organization in Israel, initiated an intervention program aimed at reducing the prevalence rate of infantile anemia (IA). This study evaluated the progress made during the intervention (2005–2014) and its yield 5 years after it ended (2019).

Methods

The CHS database was retrospectively reviewed twice yearly from 2005 to 2014 for repetitive samples of children aged 9 to 18 months regarding the previous half-year interval, and a single sample in 2019. Data were collected on gender, ethnicity (Jewish/non-Jewish), socioeconomic class (SEC; low/intermediate/high), hemoglobin testing (yes/no), and hemoglobin level (if tested). Excluded were infants with documented or suspected hemoglobinopathy.

Results

At study initiation, the rate of performance of hemoglobin testing was 54.7%, and the IA prevalence rate was 7.8%. The performance rate was lower in the Jewish than the non-Jewish subpopulation. The low-SEC subpopulation had a similar hemoglobin testing rate to the high-SEC subpopulation but double the IA prevalence rate. Overall, by the end of the intervention (2014), the performance rate increased to 87.5%, and the AI prevalence rate decreased to 3.4%. In 2019, there was little change in the performance rate from the end of the intervention (88%) and the IA prevalence was further reduced to 2.7%. The non-Jewish and low-SEC subpopulations showed the most improvement which was maintained and even bettered 5 years after the intervention ended.

Conclusions

The 10-year IA intervention program introduced by CHS in 2005 led to a reduction in IA prevalence rate to about 3.5% in all sub-populations evaluated. By program end, the results in the weaker subpopulations, which had the highest prevalence of IA at baseline, were not inferior to those in the stronger subpopulations. We recommended to the Israel Ministry of Health to adopt the intervention countrywide, and we challenge other countries to consider similar interventions.

Organic Codes: A Unifying Concept for Life

Although the knowledge about biological systems has advanced exponentially in recent decades, it is surprising to realize that the very definition of Life keeps presenting theoretical challenges. Even if several lines of reasoning seek to identify the essence of life phenomenon, most of these thoughts contain fundamental problem in their basic conceptual structure. Most concepts fail to identify either necessary or sufficient features to define life. Here, we analyzed the main conceptual frameworks regarding theoretical aspects that have been supporting the most accepted concepts of life, such as (i) the physical, (ii) the cellular and (iii) the molecular approaches. Based on an ontological analysis, we propose that Life should not be positioned under the ontological category of Matter. Yet, life should be better understood under the top-level ontology of "Process". Exercising an epistemological approach, we propose that the essential characteristic that pervades each and every living being is the presence of organic codes. Therefore, we explore theories in biosemiotics and code biology in order to propose a clear concept of life as a macrocode composed by multiple inter-related coding layers. This way, as life is a sort of metaphysical process of encoding, the living beings became the molecular materialization of that process. From the proposed concept, we show that the evolutionary process is a fundamental characteristic for life's maintenance but it is not necessary to define life, as many organisms are clearly alive but they do not participate in the evolutionary process (such as infertile hybrids). The current proposition opens a fertile field of debate in astrobiology, epistemology, biosemiotics, code biology and robotics.

Cognitive and affective processes of prosociality

One piece of the puzzle to prosocial behavior is understanding its underlying cognitive and affective processes. We discuss how modeling behavior in social dilemmas can be expanded by integrating cognitive theories and attention-based models of decision processes, and models of affective influences on prosocial decision-making. We review theories speaking to the interconnections of cognition and affect, identifying the need for further theory development regarding modeling moment-by-moment decision-making processes. We discuss how these theoretical perspectives are mirrored in empirical evidence, drawn from classical outcome-oriented as well as contemporary process-tracing research. Finally, we develop perspectives for future research trajectories aiming to further elucidate the processes by which prosocial decisions are formed, by linking process measures to usually unobservable cognitive and affective reactions.

Examining the challenges of hospital discharge for patients with a urinary catheter

BACKGROUND

Patient discharge between acute and secondary care will be viewed differently based on the stakeholder groups involved. Examining these different perceptions may help improve the discharge process and the patient journey from hospital to home.

AIMS

To determine the perceptions of community and hospital nursing staff regarding the challenges that exist with the general hospital discharge process for patients with a urinary catheter.

METHODS

A survey was created and sent to a wide range of acute and community nurses and the subscriber list of Journal of Community Nursing, Journal of General Practice Nursing and Wound Care Today.

FINDINGS

Compared with hospital staff, the opinions of community staff were more negative around the discharge process and post-discharge care and materials.

CONCLUSIONS

Results of this survey provide insight into the perceptions of nursing staff into general patient discharge for those with a urinary catheter and help identify the challenges that exist on the patient journey from hospital to home.

Case Examples and Process-Oriented Questions in Teletherapy with Couples and Families

This paper shares learned experiences in teletherapy (also called tele-mental-health, remote video therapy, and virtual therapy) with couples and families. It aims to enhance teletherapy practice with couples and families by providing tools for screening and coaching. The paper describes common pitfalls in teletherapy with couples and families and how to avoid or address them, describes the opportunities for added insight when engaging couples and families in teletherapy from their homes, provides concrete interventions in the form of process-focused questions which therapists can draw from, and provides case examples. The case examples and process-oriented questions focus on four areas: screening, logistical coaching of technology, using the family's meeting place to learn about the family, and avoiding pitfalls.

Is the Mind a Network? Maps, Vehicles, and Skyhooks in Cognitive Network Science

Cognitive researchers often carve cognition up into structures and processes. Cognitive processes operate on structures, like vehicles driving over a map. Language alongside semantic and episodic memory are proposed to have structure, as are perceptual systems. Over these structures, processes operate to construct memory and solve problems by retrieving and manipulating information. Network science offers an approach to representing cognitive structures and has made tremendous inroads into understanding the nature of cognitive structure and process. But is the mind a network? If so, what kind? In this article, we briefly review the main metaphors, assumptions, and pitfalls prevalent in cognitive network science (maps and vehicles; one network/process to rule them all), highlight the need for new metaphors that elaborate on the map-and-vehicle framework (wormholes, skyhooks, and generators), and present open questions in studying the mind as a network (the challenge of capturing network change, what should the edges of cognitive networks be made of, and aggregated vs. individual-based networks). One critical lesson of this exercise is that the richness of the mind as network approach makes it a powerful tool in its own right; it has helped to make our assumptions more visible, generating new and fascinating questions, and enriching the prospects for future research. A second lesson is that the mind as a network-though useful-is incomplete. The mind is not a network, but it may contain them.

Enhancement of Cell-based Vaccine Manufacturing Through Process Intensification

There are many drivers to intensify the manufacturing of vaccines. The emergence of SARS-CoV-2 has only added to them. Since the pandemic began, we are seeing an acceleration of vaccine development and approval, including application of novel prophylactic vaccine modalities. We have also seen an increase in the appreciation and general understanding of what had been a somewhat obscure discipline. Concurrently, there has been great interest in the application of new understandings and technology to the intensification of biopharmaceutical processes in general. The marriage of these developments defines the field of vaccine manufacturing process intensification. Difficulties in its implementation include the many disparate vaccine types- from conjugate to hybrid to nucleic-acid based. Then, there are the respective and developing manufacturing methods, modes, and platforms- from fermentation of transformed bacteria to the bioreactor culture of recombinant animal cells to production of virus-like particles in transgenic plants. Advances are occurring throughout the biomanufacturing arena, from process development (PD) techniques to manufacturing platforms, materials, equipment, and facilities. Bioprocess intensification refers to systems for producing more product per cell, time, volume, footprint, or cost. The need for vaccine manufacturing process intensification is being driven by desires for cost control, process efficiency, and the heightened pressures of pandemic response. We are seeing great interest in the power of such disciplines as synthetic biology, process simplification, continuous bioprocessing, and digital techniques in the optimization of vaccine PD and manufacturing. Other powerful disciplines here include process automation, improved monitoring, optimized culture materials, and facility design. The intent of this short commentary is to provide a brief review, and a few examples of the exciting advances in the equipment, technology and processes supporting this activity.

Quality of maternal and newborn health care in Ethiopia: a cross-sectional study

Background

Despite reports of universal access to and modest utilization of maternal and newborn health services in Ethiopia, mothers and newborns continue to die from preventable causes. Studies indicate this could be due to poor quality of care provided in health systems. Evidences show that high quality health care prevents more than half of all maternal deaths. In Ethiopia, there is limited knowledge surrounding the status of the quality of maternal and newborn health care in health facilities. This study aims to assess the quality of maternal and neonatal health care provision at the health facility level in four regions in Ethiopia.

Methodology

This study employed a facility-based cross-sectional study design. It included 32 health facilities which were part of the facilities for prototyping maternal and neonatal health quality improvement interventions. Data was collected using a structured questionnaire, key informant interviews and record reviews. Data was entered in Microsoft Excel and exported to STATA for analysis. Descriptive analysis results are presented in texts, tables and graphs. Quality of maternal and neonatal health care was measured by input, process and outputs components. The components were developed by computing scores using standards used to measure the three components of the quality of maternal and neonatal health care.

Result

The study was done in a total of 32 health facilities: 5 hospitals and 27 health centers in four regions. The study revealed that the average value of the quality of the maternal and neonatal health care input component among health facilities was 62%, while the quality of the process component was 43%. The quality of the maternal and neonatal health output component was 48%. According to the standard cut-off point for MNH quality of care, only 5 (15.6%), 3 (9.3%) and 3 (10.7%) of health facilities met the expected input, process and output maternal and neonatal health care quality standards, respectively.

Conclusion

This study revealed that the majority of health facilities did not meet the national MNH quality of care standards. Focus should be directed towards improving the input, process and output standards of the maternal and neonatal health care quality, with the strongest focus on process improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06680-1.

RADIAL: leveraging a learning management system to support radiology education

Increasing volume and complexity of cases in academic radiology and the drive toward pediatric sub-specialization have threatened knowledge assimilation for radiologists. There is a clear need for a system that retrieves vetted information from the excess available on the internet. Partnered with an interdisciplinary team from the Graduate School of Education, the authors created the first comprehensive learning management system (LMS) for radiology, implemented in the reading room to augment image interpretation and point-of-care education. The LMS supports quantitative analysis using a robust analytics platform to evaluate user statistics, facilitating improved quality of patient care by revolutionizing the way radiologists assimilate knowledge. This integration promises to enhance workflow and point-of-care teaching and to support the highest quality of care.

Treatment processes for microplastics and nanoplastics in waters: State-of-the-art review

In this work, established treatment processes for microplastics (MPs) and nanoplastics (NPs) in water as well as developed analytical techniques for evaluation of the operation of these processes were reviewed. In this regard, the strengths and limitations of different qualitative and quantitative techniques for the analysis of MPs and NPs in water treatment processes were first discussed. Afterward, the MPs and NPs treatment processes were categorized into the separation and degradation processes and the challenges and opportunities in their performance were analyzed. The evaluation of these processes revealed that the MPs or NPs removal efficiency of the separation and degradation processes could reach up to 99% and 90%, respectively. It can be concluded from this work that the combination of separation and degradation processes could be a promising approach to mineralize MPs and NPs in water with high efficiency.

A validated strategy to design efficient fermentation-industrial processes: agave spirit production

An industrial process is profitable when its individual unit operations are efficient and thus, this work shows a guideline for designing efficient fermentation-industrial processes for agave distilled production based on a sequential approach of optimization, beginning in the laboratory and followed by the adjustment of the variable values using the evolutionary operation method for successful process scaling. The results at the laboratory showed that a starter inoculum containing a 5 × 10⁶ cells/mL mixture of Kluyveromyces marxianus, Clavispora lusitaniae, and Kluyveromyces marxianus var. drosophilarum strains in a bioreactor containing agave syrup with 120 g/L fermented sugar, processed at a constant temperature of 33 °C and 1.0 VVM aeration for 1.6 h, led to a fermented product with a 4.18% (v/v) alcohol content after 72 h of processing time. The scale-up process results showed that the best operating conditions at the pilot-plant level were a temperature of 35 °C and aeration at 1.0 VVM for 1.2 h, which led to a fermented product with a 4.22% (v/v) total alcohol content after 72 h of processing time. These represent similar performance values for both production processes, but each one worked with their specific values of process variables, which demonstrates that each level of production had its own specific values for process variables. The volatile compound analysis shows that both distilled products contained a similar profile of volatile components that provide fruity and ethereal aromatic notes pleasant to the palate. Therefore, the process design for agave spirit production at the semi-industrial level was successfully achieved.

Inequitable access to healthcare in Africa: reconceptualising the "accountability for reasonableness framework" to reflect indigenous principles

Background

The “Accountability for Reasonableness” (A4R) framework has been widely adopted in working towards equity in health for sub-Saharan Africa (SAA). Its suitability for equitable health policy in Africa hinges, at least in part, on its considerable successes in the United States and it being among the most comprehensive ethical approaches in addressing inequitable access to healthcare. Yet, the conceptual match is yet to be examined between A4R and communal responsibility as a common fundamental ethic in SAA.

Methodology

A4R and its applications toward health equity in sub-Saharan Africa were conceptually examined by considering the WHO’s “3-by-5” and the REACT projects for their accounting for the communal responsibility ethic in pursuit of health equity.

Results

Some of the challenges that these projects encountered may be ascribed to an incongruity between the underpinning ethical principle of A4R and the communitarian ethical principle dominant in sub-Saharan Africa. These are respectively the fair equality of opportunity principle derived from John Rawls’ theory, and the African communal responsibility principle.

Conclusion

A health equity framework informed by the African communal responsibility principle should enhance suitability for SAA contexts, generating impetus from within Africa alongside the affordances of A4R.

Development of an Implementation Process Model: a Delphi study

Background

There is general scarcity of research on key elements of implementation processes and the factors which impact implementation success. Implementation of healthcare interventions is a complex process. Tools to support implementation can facilitate this process and improve effectiveness of the interventions and clinical outcomes. Understanding the impact of implementation support tools is a critical aspect of this process. The objective of this study was to solicit knowledge and agreement from relevant implementation science and knowledge translation healthcare experts in order to develop a process model of key elements in the implementation process.

Methods

A two round, modified Delphi study involving international experts in knowledge translation and implementation (researchers, scientists, professors, decision-makers) was conducted. Participants rated and commented on all aspects of the process model, including the organization, content, scope, and structure. Delphi questions rated at 75% agreement or lower were reviewed and revised. Qualitative comments supported the restructuring and refinement. A second-round survey followed the same process as Round 1.

Results

Fifty-four experts participated in Round 1, and 32 experts participated in Round 2. Twelve percent (n = 6) of the Round 1 questions did not reach agreement. Key themes for revision and refinement were: stakeholder engagement throughout the process, iterative nature of the implementation process; importance of context; and importance of using guiding theories or frameworks. The process model was revised and refined based on the quantitative and qualitative data and reassessed by the experts in Round 2. Agreement was achieved on all items in Round 2 and the Delphi concluded. Additional feedback was obtained regarding terminology, target users and definition of the implementation process.

Conclusions

High levels of agreement were attained for all sub-domains, elements, and sub-elements of the Implementation Process Model. This model will be used to develop an Implementation Support Tool to be used by healthcare providers to facilitate effective implementation and improved clinical outcomes.

Freeze-drying of nanoparticles: How to overcome colloidal instability by formulation and process optimization

Lyophilization of nanoparticle (NP) suspensions is a promising technology to improve stability, especially during long-term storage, and offers new routes of administration in solid state. Although considered as a gentle drying process, freeze-drying is also known to cause several stresses leading to physical instability, e.g. aggregation, fusion, or content leakage. NPs are heterogeneous regarding their physico-chemical properties which renders them different in their sensitivity to lyophilization stress and upon storage. But still basic concepts can be deducted. We summarize basic colloidal stabilization mechanisms of NPs in the liquid and the dried state. Furthermore, we give information about stresses occurring during the freezing and the drying step of lyophilization. Subsequently, we review the most commonly investigated NP types including lipophilic, polymeric, or vesicular NPs regarding their particle properties, stabilization mechanisms in the liquid state, and important freeze-drying process, formulation and storage strategies. Finally, practical advice is provided to facilitate purposeful formulation and process development to achieve NP lyophilizates with high colloidal stability.

Milk microfiltration process dataset annotated from a collection of scientific papers

Milk microfiltration process plays a key role in the dairy industry. Crossflow microfiltration of skimmed milk using a membrane with 0.1 µm mean pore size is widely used to fractionate the two main groups of dairy proteins: casein micelles (~150 nm) and serum proteins (~2-15 nm). Retentate, containing mainly casein micelles, is generally used to enrich vat milk for cheese making. Permeate, containing serum proteins, lactose and minerals, is usually ultrafiltered in order to produce protein-rich concentrate with a high nutritional value dedicated to specific populations such as infants and seniors. The great interest in these protein fractions explains the increasing number of microfiltration equipments in the dairy industry. This data article contains data associated with milk microfiltration process experiments and properties of the resulting dairy fractions annotated from a collection of scientific documents. These data are stored in INRAE public repository (see Data accessibility in the Specification Table for direct links to data). They have been structured using MILK MICROFILTRATION ontology and are replicated in @Web data warehouse providing additional querying tools (https://www6.inrae.fr/cati-icat-atweb/).

Executing Distributed Healthcare and Research Processes - The HiGHmed Data Sharing Framework

Several standards and frameworks have been described in existing literature and technical manuals that contribute to solving the interoperability problem. Their data models usually focus on clinical data and only support healthcare delivery processes. Research processes including cross organizational cohort size estimation, approvals and reviews of research proposals, consent checks, record linkage and pseudonymization need to be supported within the HiGHmed medical informatics consortium. The open source HiGHmed Data Sharing Framework implements a distributed business process engine for executing arbitrary biomedical research and healthcare processes modeled and executed using BPMN 2.0 while exchanging information using FHIR R4 resources. The proposed reference implementation is currently being rolled out to eight university hospitals in Germany as well as a trusted third party and available open source under the Apache 2.0 license.

Patient and family views of team functioning in primary healthcare teams with nurse practitioners: a survey of patient-reported experience and outcomes

BACKGROUND

Nurse practitioners (NPs) have been added to primary healthcare teams to improve access to care. Team processes, including communication and decision-making, explicate how patients and families view team functioning. Yet, important gaps exist in our understanding of patient-reported experience and outcomes at the level of the healthcare team. We aimed to examine the influence of individual, team, and organizational characteristics, and role clarity on outcomes of care mediated by team processes in primary healthcare teams that include NPs.

METHODS

A cross-sectional survey across six sites representing practices with NPs in Québec, Canada, was conducted between March 2018 and April 2019 as part of a multiple-case study. Patients and families (n = 485; response rate: 53%) completed a validated questionnaire, which included a patient-reported experience measure (PREM) and a patient-reported outcome measure (PROM) of team functioning (Cronbach alpha: 0.771 (PROM) to 0.877 (PREM)). We performed logistic regression and mediation analyses to examine relationships between the individual, team, and organizational characteristics, role clarity, and outcomes of care mediated by team processes.

RESULTS

Patients and families expressed positive perceptions of team functioning (mean 4.97/6 [SD 0.68]) and outcomes of care (5.08/6 [0.74]). Also, high team processes (adjusted odds ratio [AOR] 14.92 [95% CI 8.11 to 27.44]) was a significant predictor of high outcomes of care. Role clarity (indirect effect coefficient ab = 6.48 [95% CI 3.79 to 9.56]), living in an urban area (-1.32 [-2.59 to -0.13]), patient as respondent (-1.43 [-2.80 to -0.14]), and income (1.73 [0.14 to 3.45]) were significant predictors of outcomes of care mediated by team processes.

CONCLUSIONS

This study provides key insights on how primary healthcare teams with NPs contribute to team functioning, using a validated instrument consistent with a conceptual framework. Results highlight that high role clarity, living in a non urban area, family as respondent, and adequate income were significant predictors of high outcomes of care mediated by high team processes. Additional research is needed to compare teams with and without NPs in different settings, to further explicate the relationships identified in our study.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Stewardship as process: A paradox perspective

Long-term stewardship is usually represented as a stable structural condition and portrayed as a source of competitive advantage to firms (including family businesses) that use it as a mode of governance. Less is known about how organizations engage with stewardship as a process. We embrace a process approach to report a case study about the unfolding of stewardship in a multi-business family group. We conclude that stewardship is a process marked by critical tensions and paradoxes; by exploring the nature of these we uncover further dimensions and responses to the paradoxes of stewardship.

A comprehensive review of the recent development and challenges of a solar-assisted biodigester system

The extensive use of fossil fuels and the environmental effect of their combustion products have attracted researchers to look into renewable energy sources. In addition, global mass production of waste has motivated communities to recycle and reuse the waste in a sustainable way to lower landfill waste and associated problems. The development of waste to energy (WtE) technology including the production of bioenergy, e.g. biogas produced from various waste through Anaerobic Digestion (AD), is considered one of the potential measures to achieve the sustainable development goals of the United Nations (UN). Therefore, this study reviews the most recent studies from relevant academic literature on WtE technology (particularly AD technology) for biogas production and the application of a solar-assisted biodigester (SAB) system aimed at improving performance. In addition, socio-economic factors, challenges, and perspectives have been reported. From the analysis of different technologies, further work on effective low-cost technologies is recommended, especially using SAB system upgrading and leveraging the opportunities of this system. The study found that the performance of the AD system is affected by a variety of factors and that different approaches can be applied to improve performance. It has also been found that solar energy systems efficiently raise the biogas digester temperature and through this, they maximize the biogas yield under optimum conditions. The study revealed that the solar-assisted AD system produces less pollution and improves performance compared to the conventional AD system.